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The Making of a Neurosurgeon: Dr. Robert Solomon

A Choice of Paths

When Robert Solomon was a young man, he faced a decision: medicine or art.

Each had its advantages. Solomon’s father was a doctor, and “it was just sort of ingrained from childhood,” he says, that medicine would be a rewarding and useful profession. But then, he had always loved the hands-on, mechanical process of building furniture in his grandfather’s lumberyard. During his undergraduate courses at Yale, Solomon discovered how much he enjoyed etching and printmaking—the processes of working with his hands to create exactly the right fine detail. Maybe, he thought, art was his calling after all.

“I discussed it with my parents,” he says. “I told them, ‘I think I’m dropping out of molecular biochemistry and biology, and I’m going to do a fine art major.’ ” But, he added, “that didn’t go over so well.” Solomon’s father convinced him to stay with medicine. And it’s a good thing he did.

Today, Dr. Robert Solomon is the Chairman of Columbia Neurosurgery. But he didn’t give up his artist’s vision, his craftsman’s eye for detail and necessity, or his facility with his hands. Instead, he turned those talents to medicine, using them to conduct research, perform life-saving surgery, make groundbreaking innovations and build a neurosurgery department that is renowned in the field for its balance and harmony.

In order to do all that—for fate to play a part in his becoming a neurosurgeon at all—first the young Solomon would have to get turned down for a summer job.

When Down Turns Up

After graduating from Yale with honors, Solomon was accepted to one of the top medical schools in the world, Johns Hopkins. During his first year there he felt pretty sure surgery would be a good fit because he liked working with his hands. He hoped to spend the summer after that first year learning more about surgery, so he went to the director of surgery at Johns Hopkins to ask about a summer job.

“He was completely annoyed by my coming to see him,” said Dr. Solomon, clearly recalling the cold shoulder he got from that director. “He tried as best he could to blow me off. He said, ‘Go talk to the chairman of neurosurgery. He’s a young guy, just started. Maybe he’ll have something for you.”

As it turned out, the neurosurgery chairman “was really a very nice guy” who did have something for Solomon. He offered him a summer job working in his pain clinic, with occasional opportunities to come to the operating room and observe surgery. Solomon took the job in a heartbeat.

Though it was no fun to be so thoroughly dismissed by the surgery director, Dr. Solomon ended up with two reasons to be grateful that it happened. The first: “I realized as I advanced,” Dr. Solomon recalls, “how important it is to treat medical students and younger people correctly—with a lot of respect—and to be helpful.” Now that he’s the Chairman of a preeminent neurosurgery department, that lesson has guided his actions and affected the lives of all the medical students and residents who have trained under him. Today, Dr. Solomon is known for treating all people, no matter who they are or where they are from, with respect.

The second reason? Solomon did spend that summer working in the neurosurgery department, doing research and observing surgery. He loved it, and it set the course for the rest of his life.

“Once I got neurosurgery in my blood, I couldn’t get rid of it,” he says. “As I got further in medical school, I compared everything with neurosurgery, and nothing really even came close. It was clear to me that that was what I wanted to do.”

An Exciting Model—and the Seed of a Big Idea

After four years of medical school, Dr. Solomon came to Columbia University Medical Center to train as a neurosurgeon.

At the time, most neurosurgery departments consisted of individual neurosurgeons who all vied to be the best in every single neurosurgical specialty. But Columbia’s department had just come under the leadership of Dr. Bennett Stein, who wanted to build a new kind of neurosurgery department. The department, he hoped, would eventually be based on cooperation among sub-specialists. One surgeon would focus deeply on tumors of the brain, for instance, and another on the spine. When it made sense, those sub-specialists could collaborate, each bringing an area of deep expertise to bear on a particular case. To Dr. Solomon, the idea made a lot of sense. It sounded like the future of neurosurgery.

Dr. Robert Solomon with Dr. Bennett Stein

So he began the seven-year training program called residency. Dr. Jost Michelsen was one of Dr. Solomon’s teachers during that time. He recalls that Dr. Solomon “was a splendid surgeon. He was careful, precise, didn’t waste energy or time, always prepared. He took good care of the patients, and he thought about them. He was an extremely thoughtful resident, and everybody liked him.”

It was during his time as a resident, caring for and thinking about his patients, that Dr. Solomon had the seed of a very big idea.

Dr. Solomon had many patients with ruptured brain aneurysms. A brain aneurysm is a weak, ballooning area in a blood vessel in the brain. If the aneurysm ruptures, it releases blood into the brain—a serious medical emergency. Today, about 60 percent of patients survive a ruptured brain aneurysm. But at the time, in the early 1980s, the odds of surviving a ruptured aneurysm were dismal.

There are two ways a ruptured aneurysm can be fatal. The first happens extremely quickly: If the hemorrhage (bleeding) does not stop on its own, there is no medicine or surgery that can usually act fast enough to save a patient’s life. That’s still as true today as it was in the 1980s.

But often a patient’s bleeding does stop on its own, at least temporarily. This condition is still very dangerous: The brain has experienced trauma from the bleeding, and the ruptured aneurysm can start bleeding again at any time. Doctors didn’t have a great way to treat these patients, but Dr. Solomon thought he saw a way to help.

A Rock and a Hard Place

The root of the problem for these patients, explains Dr. Solomon, is that “when blood spills out of a ruptured aneurysm, it irritates the blood vessels and causes them to go into spasm, called vasospasm. They narrow and restrict blood flow to the brain, causing cerebral ischemia (restriction of blood flow in the brain). If the vasospasm gets severe enough, it can cause a stroke.” Surgery to close off the aneurysm would simply irritate the sensitized vessels, worsening the vasospasm. The aneurysm would be repaired, but the patient would have a stroke.

So surgeons were between a rock and a hard place. To avoid worsening the vasospasm, explains Dr. Solomon, “surgeons wouldn’t operate on patients for two weeks after rupture.” But in those two weeks, patients’ lives were often claimed, either by vasospasm from the original rupture or by a re-rupture causing hemorrhage or vasospasm.

That was the situation when Dr. Solomon read an interesting medical paper. It described how some doctors counteracted vasospasm elsewhere in the body by keeping a patient’s hydration and blood pressure high. He started keeping track of patients in the hospital. He found that the aneurysm patients who died because of vasospasm were generally the ones who were more dehydrated and had lower blood pressure. But it was inadvisable to just raise those patients’ blood pressure and hydration—that would likely cause their brain aneurysms to rupture again.

Enter Dr. Solomon’s idea. Maybe, he thought, neurosurgeons could operate on an aneurysm immediately, preventing it from ever rupturing again. Directly afterward, surgeons could counteract vasospasm by keeping patients’ blood pressure and hydration elevated. That way both dangers would be addressed: The re-rupture would be prevented by the aneurysm repair surgery, and then the vasospasm could be prevented by elevated blood pressure and hydration. He read more widely and contacted other neurosurgeons. “A lot of Japanese neurosurgeons had been talking about doing this,” he recalls. “But nobody had made it standard practice.”

Dr.Robert Solomon & his wife Barbara Solomon

The Idea Takes Root

Once he had completed his residency and was hired as a permanent member of the Department of Neurosurgery at Columbia, Dr. Solomon and neurologist Dr. Matt Fink implemented this new method. Right away, he says, “the results were outstanding.” Soon, all the surrounding emergency rooms were sending their ruptured aneurysm cases to Dr. Solomon. “The other hospitals were all delighted to be able to send us their aneurysm patients,” says Dr. Solomon, “because otherwise the patients were dying… For a while, we were very, very busy doing ruptured aneurysms.”

At first, Dr. Solomon was the only neurosurgeon in New York treating aneurysms in this way. He energetically spread the word about the method, though, so that all doctors and patients could benefit from the new procedure. And it worked. He implemented the immediate-treatment approach in the mid to late ’80s; by the early ’90s, it had become standard practice worldwide.

Dr. Solomon speaks about popularizing this approach as the most important contribution he has made to neurosurgery. The scope of his positive results—the sheer number of lives saved from the many nearby emergency departments—helped him prove the efficacy of the method and spread the word about it quickly.

A Knack for Solutions

Dr. Solomon turned out to have a knack for finding solutions to tough problems in aneurysm surgery.

For his next innovation, he teamed up with a cardiac surgeon to handle aneurysms that were extraordinarily risky to operate on. These were bulging aneurysms so delicate that the process of performing the operation itself might rupture them—with potentially devastating results. Today, these aneurysms are often treated with modern endovascular techniques. But at the time, patients with such aneurysms sometimes could not be helped at all.

Dr. Solomon didn’t want to accept telling patients that their fragile aneurysms could not be treated. To help the patients with the riskiest of aneurysms, he paired with young cardiac surgeon Dr. Craig Smith, a fellow faculty member at Columbia’s medical school. The two young surgeons improved on a long-standing procedure. This incredible procedure requires something that is otherwise nearly unheard of during surgery: stopping a patient’s heart. But for patients without any other options, the benefits outweighed the risks.

Here’s how it worked: When the heart stopped beating, the patient’s aneurysm was no longer being pumped full of blood. It was not taut and fragile like a bulging balloon anymore. Instead, it was like a deflated balloon—much safer to handle. An adept neurosurgeon could safely access and treat the aneurysm in its deflated state, even if that would not have been possible in its bulging state.

Normally, a lack of blood flow to the brain quickly produces brain damage. But this procedure relied on the protective effects of hypothermia. Hypothermia, a state of deep cooling of the body, temporarily protects against brain damage. For example, occasionally an individual can apparently drown in icy water, only to be resuscitated 10, 20, even 30 minutes later. Hence the first responders’ maxim that patients are “not dead till they’re warm and dead”—when the body is very cool, it may be protected by hypothermia.

Surgeons had realized this decades before and tried to use hypothermia to protect the body while stopping the heart during surgery. But the technology at the time was against them. In its original form, the procedure required not only opening the skull, but also opening the chest to administer electric shocks that stopped and re-started the heart. Hypothermia was induced from the outside in, by packing the patient’s body in ice. There were successes, but under these circumstances, it was hard to say whether the benefits outweighed the risks. The procedure fell out of use.

Dr. Solomon and cardiac surgeon Dr. Smith saw a way to use new technology to make the procedure vastly safer. The surgeons attached a cardiopulmonary bypass machine to a blood vessel in the groin. The machine could handle circulating the blood through the body. The machine also cooled the blood, inducing hypothermia from the inside out. When hypothermia was achieved, the heart automatically stopped beating; no open chest surgery was necessary. The surgeons would have the machine stop circulating the blood, and Dr. Solomon would begin work on the aneurysm. As soon as Dr. Solomon clipped the aneurysm, the bypass machine could be re-started, circulating and gradually warming the blood. The heart then started beating again on its own when it was warm enough.

“It was still very dangerous, as you can imagine,” says Dr. Solomon. “But it was only for the most dangerous of aneurysms.” Treating the most dangerous of aneurysms in this way, the doctors had overwhelmingly positive results.

Today, this approach is not necessary. “With the advent of modern endovascular techniques,” explains Dr. Solomon, “these approaches became obsolete. But we were able to help several patients who otherwise could not have been helped at the time. There were some amazing success stories.” He continues with a smile, “We still get letters from patients we operated on in 1988.”

A Master Builder

When Dr. Solomon became Chairman of the department, there were just seven neurosurgeons. Each one focused deeply on a different subspecialty: tumors, spine, blood vessels, pediatrics, etc. As the reputations of these sub-specialists grew, so did the number of patients who wanted to see them.

Whenever any of the original specialists felt too busy to see all the patients who asked for appointments, or couldn’t see patients as quickly as the patients needed, Dr. Solomon made another hire. The department hired only outstanding surgeons who were also team players.

The new hire worked directly with the original specialist, benefiting from the senior surgeon’s guidance and experience. Quickly, the junior associate gained experience and built his or her own reputation. Over the years, this happened time and again. Now Columbia has a department of 20 neurosurgeons, and still each one focuses deeply on his or her own subspecialties. The department runs harmoniously, and this deep specialization brings the best possible care to patients.

Dr. Michelsen, the mentor from Dr. Solomon’s early years as a trainee resident, calls the gradual construction of this well-balanced department one of Dr. Solomon’s “greatest accomplishments.” Dr. Stein, another great mentor and the Chairman before Dr. Solomon, agrees with that assessment. It was far from easy to create a truly cooperative team composed of expert neurosurgeons. But, he says, “Bob has been able to pull it off, and they really respect his leadership. He doesn’t lord [his position] over them, and he lets them develop their own talents, which is what I always felt Chairmen should do. I respect him greatly for that.”

Over the years, at the same time he was making lifesaving neurosurgical innovations, performing surgery and research, chairing a department and leading neurosurgical societies, he didn’t let his love of art and woodworking flag. He has filled his home with custom furniture for his family, and he makes the occasional gift for a close friend—he likes making things with a purpose. “I’m sort of scientific about it,” he says. Today he’s “threatening to go back and do more art classes,” delving into the fine detail and the process—aspects of neurosurgery he also excels at.

Dr. Solomon today

Once an artist, always an artist. Once a scientist, always a scientist. To the benefit of many people in this department and around the world, Dr. Robert Solomon is both.

Looking back, does he regret choosing medicine over art? “Not at all,” he says. “It was the right choice. My life has been much more productive by focusing on medicine and neurosurgery. I have been able to help many people, and that is very rewarding.”

Learn more about Dr. Solomon at his bio page here.

patient journey

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